The present invention relates generally to ultrasonic imaging and more particularly, to a method for detecting and imaging brachytherapy “seeds” using ultrasound signals.
Brachytherapy is a type of radiation therapy commonly used to provide local radiation for the treatment of localized cancers. One form of brachytherapy places multiple small cylindrical seeds of radioactive material inside or adjacent to a malignant tumor in order to emit radiation that can thwart the growth of cancer cells or kill them. Brachytherapy seeds are commonly used in treating gland-confined prostate cancer, but may also be used to treat brain cancers, breast cancers, and gynecological cancers. Seeds used in treating prostate cancers are generally small titanium-shelled radioactive seeds containing radioactive iodine (I125) or palladium (Pd103). The seeds are 4.5-mm to 5-mm long and 0.8 mm in diameter and consist of a thin, rigid, titanium shell enclosing the radioactive material.
Transrectal ultrasound (TRUS) is a standard imaging method frequently used to plan and guide implantation of brachytherapy seeds in the prostate. The TRUS probe is mounted on a fixture that contains a needle-guidance template, which rests against the perineum and incorporates detents enabling the probe to be introduced into or withdrawn from the rectum in 5-mm steps. Scans are oriented in a transverse plane perpendicular to the probe axis. The fixture is advanced into the rectum until the seminal vesicles are imaged and images of the prostate and adjacent tissues are generated.
TRUS images are ported through a standard output jack to a laptop computer on which treatment-planning software is run. An example of such software is VariSeed by Varian Medical Systems, Inc. (VMSI), of Charlottesville, Va. This treatment-planning software generates an image of available and optimal needle locations, which are fixed by the template used for needle guidance. The oncologist demarcates the prostate in each scan plane and prescribes a radiation dose for the gland as a whole. The planning software then presents a set of suggested seed positions in each scan plane, which the oncologist can accept or reject based on isodose distributions plotted by the software for whatever seed positions are chosen.
The software bases the isodose distributions on seed locations in the 3-D volume spanned by the set of scan planes in the planning set. Immediately after planning is completed, gland-immobilizing needles are inserted, and then seed-implantation needles are loaded with the radioactive seeds and plastic spacer seeds in a manner that places radioactivity at the specified depths, corresponding to the scan planes, along each needle position. The spacer seeds are not visible in ultrasonic or x-ray computed tomography (CT) images. Loaded needles are then inserted into the prostate via the perineum and through the template holes that match the needle positions depicted on the planning-software image. Dosimetric evaluation subsequently is performed using post-implant CT imaging. Traditionally, post-implant CT scans are performed within two to four weeks of implantation, but current practice tends to favor post-implant CT imaging within 24 hours of implantation.
Despite the use of gland-immobilizing needles, implantation using needles inserted transperitoneally causes gland movement and distortion, which often results in seed misplacement and dosimetry errors. In some cases, the CT scans show that the actual locations of implanted seeds differ markedly from their planned locations. Studies by Potters, et al., have shown that 30% of prostate brachytherapy procedures result in a dose to 90% of the prostate that is less than the prescribed dose. [Potters, et al., Int. J. Radiat. Oncol. Biol. Phys., 50:605 614, 2001]. Studies by Stock, et al., showed that 32% of under-dosed patients have biochemical failure (as evidenced by a rise in the blood level of prostate-specific antigen (PSA)) within four years, whereas only 8% of properly dosed patients have biochemical failure. [Stock, et al, Int. J. Radiat. Oncol. Biol. Phys., 41:101 108, 1998]. The conventional B-mode ultrasound images generated at the time of the procedure do not allow adequate visualization of the placed seeds because of clutter from calcifications and other hyperechogenic scattering objects, shadows caused by hemorrhage or by other seeds, and loss of echo signals due to seed angulation. Clutter often increases immediately during the procedure from hemorrhage and edema caused by the trauma of needle insertion. Other impairments in properly imaging seeds result from strong specular reflections of ultrasound waves reflected off the smooth titanium metal shell of brachytherapy seeds.
U.S. Pat. No. 7,217,242 describes an ultrasonic method for visualizing brachytherapy seeds. This patent is assigned to the same assignee as is the present application and the teachings of this patent are incorporated herein by reference. The invention described in the '242 patent is directed to a method for imaging therapeutic seeds in tissue by determining at least one mechanical resonant frequency for the seeds, stimulating the seeds with a first acoustic signal having a frequency corresponding to the resonant frequency and imaging the seeds with a second acoustic signal at a higher frequency. A Doppler method is used to detect vibratory motion and thus image the seeds. Although the method described in the '242 patent is a substantial advance over prior art methods for imaging therapeutic seeds, further advances are possible as described herein.
Currently, dosimetry corrections for seed misplacement are made after implantation and not intraoperatively. Accordingly, an imaging system is desired that can image seeds contemporaneous with seed implantation. A method is also desired that permits optimal seed placement and accurate dose distribution. An imaging system that provides accurate, post-insertion, seed-location information is also needed. Such real-time information would enable a physician to correct radiation dosage deficiencies intraoperatively in a patient by implanting additional seeds where needed. Finally, a method is desired to localize and image seeds and allow seed detection and depiction to be performed independently of transducer technology or beam-forming algorithms.